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°pow., 0, SAN JOAQUIN <br />MV <J —COUNTY <br />\\,,,_451113_7ay- 0 Greatness grows here <br />Environmental Health Department <br />COTTAGE FOOD OPERATIONS (CFO) <br />REGISTRATION/PERMITTING RENEWAL FORM <br />I / c.FO-Business Nam : ( Owner Name: <br />r(11161 013 3 5,-n 67s Frok )Lit(\ Dwn Date. <br />4 oF0 Physical ddres5: , — CFO City: <br />I N • \. PUrti/ ,5+4,1"br) (4- qS•Oz.' <br />Website (If applicable): Telephone szoq-qo 6 - aOn <br />1. Categories: <br />[4] "Class A" (Direct Sales Only) $186 E "Class B" (Direct & Indirect Sales) $312 <br />Prohibited Items: Initial if you agree to abide by the following: <br />Foods containing cream, custard, or meat fillings are potentially hazardous and are NOT ALLOWED. Only <br />foods that are defined as "non-potentially hazardous" are approved for preparation by a Cottage Food Operation. <br />These foods include items that do not require refrigeration to keep them safe from bacterial growth that could be a <br />cause of food-borne illness. <br />Products: <br />Provide a list of all products you are preparing. If preparing jams, jellies, or fruit butters include a list of <br />ingredients (attac,b,separate page if needed). <br />Food List: efIch (øht <br />/,ta (ci-e- <br /> <br />a90 d <br />Product Labeling: <br />Attach one label to this form for two of your CFO products (only one label is required if only one product is <br />made). <br />Water Source: <br />Please check what type of water source is being used at the CFO: <br />City Water n Private Well* <br />*If a private well, attach all updated water sample results (including quarterly bacteria and Nitrate results.) <br />Food Processor Course: <br />Attach food handler certification for owner and each individual that were not submitted with initial application <br />(including family members and/or employees). <br />1868 E. Hazelton Avenue I Stockton, California 95205 I T 209 468-3420 I F 209 464-0138 I www.sjcehd.com